PSP typically manifests in young men who are tall, thin, and likely to be smokers [9]. This subtype occurs in ages of 20 to 30 years. However, SSP develops in individuals aged 60 to 65 who exhibit underlying disease.

The presentation typically consists of a sudden onset of sharp pleuritic pain, which may radiate to the neck, shoulder, or abdomen. The pain subsides within 24 hours [10] as the lung adapts by slowly re-inflating.

The features are varied as some patients have mild dyspnea while others develop sequelae such as shock and possibly death. Factors that determine the severity include the amount of air that enters the pleural space, the percentage of lung collapse, and the baseline lung function.

Physical exam

Clinical findings that reflect a large pneumothorax include decreased or absent breath sounds, less movement of the chest wall, tympanic percussion, and reduced tactile fremitus [11]. Additionally, reflex tachycardia is common.

• Pain

  The duration of operation, hospital stay days and inpatient pain scores were compared between each group. [ncbi.nlm.nih.gov]

  Our suggestion is to take one day at a time. 8-You may have to become an expert in chronic pain management. In addition to blebs being painful, the surgical treatment of collapsed lungs may leave you living with chronic pain. [therapyinphiladelphia.com]

• Collapse

  Careful follow-up is very important because a considerable number of patients with mild lung collapse eventually require an invasive medical procedure. [ncbi.nlm.nih.gov]

  Factors that determine the severity include the amount of air that enters the pleural space, the percentage of lung collapse, and the baseline lung function. [symptoma.com]

  Pneumothorax is a collection of air or gas in the pleural cavity (chest) that causes the lung to collapse. When this happens without an injury to the chest it is called spontaneous pneumothorax. [laparoscopyindia.com]

  Learn more about surgery for collapsed lung. [chop.edu]

• Inflammation

  Abstract Granulomatosis with polyangiitis (GPA) (Wegener's) is a multiorgan system disease of unknown aetiology characterised by granulomatous inflammation, tissue necrosis and vasculitis. [ncbi.nlm.nih.gov]

  This inflammation causes the pleurae to stick together (adhere) eliminating the pleural space. Another procedure, called pleural abrasion, can also be used to cause inflammation and adhesion of the pleurae. [rarediseases.org]

  During surgery, your surgeon brushes the pleura to cause inflammation. Chemical pleurodesis is another form of treatment. Your doctor will deliver chemical irritants to the pleura through a chest tube. [healthline.com]

  The pathological process includes emphysema-like changes, pleural porosity and inflammation. [karger.com]

  Smoking causes inflammation in the small airways leading to tissue damage referred to as emphysematous-like changes (ELCs). In general, PSP is more common in men than women. [thoracicgroup.com]

• Surgical Procedure

  Two recurrent pneumothoraxes in 2 patients were observed after surgical procedures for PSP. One recurrence developed in the non-intubated group (7%) and one in the intubated group (5%). [ncbi.nlm.nih.gov]

  Another surgical procedure that has been used to treat some affected women involves a mesh made from specialized material. [rarediseases.org]

  The surgical procedure involves using a minimally invasive technique in which the apical blebs are removed along with a portion of the lining of the chest ( pleura ). [thoracicgroup.com]

• Fatigue

  Mental fatigue can manifest as somnolence, lethargy, or directed attention fatigue.[4] Fatigue and 'feelings of fatigue' are sometimes confused.[5] Unlike weakness, fatigue usually can be alleviated by periods of rest. [en.wikipedia.org]

  […] the following; Symptoms Acute onset chest pain – severe and/or stabbing pain, radiating to ipsilateral shoulder and increasing with inspiration (pleuritic) Sudden shortness of breath Anxiety, cough and vague presenting symptoms (e.g. general malaise, fatigue [rch.org.au]

  Patients with a collapsed lung may experience a sudden onset of the following symptoms: Sharp chest pain, made worse by a deep breath or a cough Shortness of breath A larger pneumothorax will cause more severe symptoms, including: Chest tightness Easy fatigue [chop.edu]

  Fatigue. Rapid breathing. Rapid heartbeat. Cough. Cleveland Clinic News & More Cleveland Clinic News & More [my.clevelandclinic.org]

• Pneumonia

  A histological examination of the macular lesions revealed that they were aspiration pneumonia foci with many birefringent foreign materials. [ncbi.nlm.nih.gov]

  Pneumocystis jirovecii pneumonia occurs mainly in patients on chronic immunosuppressive drugs or with immune deficiency due to HIV infection. [mdedge.com]

• Cough

  Pulmonary affection usually starts with unspecific symptoms such as cough, dyspnea, hemoptysis, and pleuritis. Pulmonary nodules are 1 of the most common manifestations. The prevalence of pleural affection is 10 to 20%. [ncbi.nlm.nih.gov]

  Take a cough suppressant to avoid coughing, if your healthcare provider recommends it. Avoid smoking. Ask your healthcare provider if you should be doing breathing exercises and, if so, how you should be doing them. [summitmedicalgroup.com]

  […] healthy persons artificial pneumothorax aspiration of air atelectasis barometric pressure bleeding breath sounds Bronchoscopic examination bullae cent chemical pleuritis chest wall clavicles collapsed lung condition of lungs Constitutional symptoms coughing [books.google.com]

• Dyspnea

  Case 1, a 43-year old man was admitted to our hospital with dyspnea 10 days before admission. He denied any recent trauma or previous treatment for lung tuberculosis. [ncbi.nlm.nih.gov]

  Shortness of breath Other names Dyspnea, dyspnoea, breathlessness, difficulty of breathing, respiratory distress Pronunciation Dyspnea: /dɪspˈniːə/ Specialty Pulmonology Shortness of breath (SOB), also known as dyspnea, is a feeling of not being able [en.wikipedia.org]

• Pleural Effusion

  Re-expansion pulmonary edema (RPE) is a rare but potentially fatal complication that can occur following rapid lung expansion while managing patients with pleural effusion or pneumothorax. [ncbi.nlm.nih.gov]

  effusion, not elsewhere classified J91 Pleural effusion in conditions classified elsewhere J91.0 Malignant pleural effusion J91.8 Pleural effusion in other conditions classified elsewhere J92 Pleural plaque J92.0 Pleural plaque with presence of asbestos [icd10data.com]

  […] adhesions pleural effusion pleural space pneumothorax in tuberculous pneumothorax occurring pneumothorax space previously healthy person pulmonary tuberculosis reach the pleural recovery recurrent pneumothorax ribs severe simple pneumothorax sions spontaneous [books.google.com]

  effusions are commonly present If chest radiograph is taken in supine position, signs of pneumothorax include: Deep sulcus sign; lucency along the costophrenic angle is abnormally deepened Hyperlucency of the affected side CT scan is not recommended [rch.org.au]

• Decreased Breath Sounds

  Examination may be abnormal (decreased breath sounds, symmetric chest rise, etc); however, small Ptx’s or Ptx’s in smaller children may produce no identifiable physical exam abnormalities. [pedemmorsels.com]

  Tachycardia is the most common finding and, depending on the amount of lung involved, other physical findings include decreased chest wall movement, a hyperresonant percussion note, diminished fremitus and diminished or decreased breath sounds. [aafp.org]

  The health care provider will listen to your breathing with a stethoscope. If you have a collapsed lung, there are decreased breath sounds or no breath sounds on the affected side. You may also have low blood pressure. [medlineplus.gov]

  Signs Examination may be unremarkable Tachycardia may be the only clinical finding (single most common finding) Keep high index of suspicion COPD patients Tall, thin males Changes on affected side Unilateral absent or decreased breath sounds Hyperresonance [fpnotebook.com]

• Chest Pain

  Dyspnea and chest pain suddenly appear during successful chemotherapy for metastatic chemosensitive tumors should alert the physician to the possibility of SP. The treatment is directed toward lung re-expansion. [ncbi.nlm.nih.gov]

  A study has shown that the stress of labour is usually assumed to be the cause of chest and abdominal pain post partum 4. [ispub.com]

• Cyanosis

  The most severe forms of pulmonary alveolar proteinosis, in which hypoxemia and cyanosis occur, have a high mortality risk during anaesthesia and whole lung lavage. [ncbi.nlm.nih.gov]

  […] persons artificial pneumothorax aspiration of air atelectasis barometric pressure bleeding breath sounds Bronchoscopic examination bullae cent chemical pleuritis chest wall clavicles collapsed lung condition of lungs Constitutional symptoms coughing cyanosis [books.google.com]

  Rapidly evolving hypotension, tachypnea, tachycardia and cyanosis should raise the suspicion of tension pneumothorax, which is, however, extremely rare in PSP. [err.ersjournals.com]

  Decreased or absent breath sounds Hyperresonance on percussion Asymmetric lung expansion, mediastinal and tracheal shift with large pneumothorax Signs of tension pneumothorax Deviation of the trachea to the contralateral side, tachycardia, hypotension, cyanosis [rch.org.au]

  Cyanosis or blueness of the skin will occur as the tissues lose their oxygen. Decreased levels of consciousness may occur because of the low blood pressure, decreased brain perfusion, and low oxygenation. [emedicinehealth.com]

• Heart Failure

  […] and efforts to increase blood flow.[2] Congestive heart failure[edit] Congestive heart failure frequently presents with shortness of breath with exertion, orthopnea, and paroxysmal nocturnal dyspnea.[2] It affects between 1–2% of the general United States [en.wikipedia.org]

• Fear

  Occasionally, extreme anxiety over placement of a chest tube or fear of another pneumothorax may be reason to perform surgery at the first episode of pneumothorax. [ctsnet.org]

• Confusion

  […] the term spontaneous pneumothorax to those instances in which the etiology is not demonstrable by our clinical examination, but I believe that these might be more properly classified as the idiopathic type of spontaneous pneumothorax in order to avoid confusion [annals.org]

  Symptoms Symptoms of pneumothorax may hardly be noticeable at first and can be confused with other disorders. [medicalnewstoday.com]

  Here is a still pointing out the different structures that are seen if you are confused as to what you are looking at: Now, the emergency providers just needed to prove there was a pneumothorax to other providers in the hospital so a chest x-ray was ordered [hennepinultrasound.com]

  I'm just studying respiratory path right now and I remembered Goljan's explanation from a while back when i was lisetning to him at the gym and got confused. [forums.studentdoctor.net]

  Mental fatigue can manifest as somnolence, lethargy, or directed attention fatigue.[4] Fatigue and 'feelings of fatigue' are sometimes confused.[5] Unlike weakness, fatigue usually can be alleviated by periods of rest. [en.wikipedia.org]

• Paresthesia

  A uniportal approach has been shown to cause less pain and paresthesias compared to conventional thoracoscopy [13]. [ctsnet.org]

• Seizure

  Tuberous sclerosis complex can involve the nerves (seizures, brain tumors), the lungs (lymphangioleiomyomatosis, causing pneumothorax or chylothorax), and the skin; skin lesions include facial angiofibromas ( Figure 1 ), ash-leaf spot ( Figure 2 ), and [mdedge.com]

The clinical assessment consists of the patient's history, the physical exam, and the appropriate tests. A large pneumothorax is diagnosed based on the exam findings.

Imaging

A pneumothorax on a chest radiograph is depicted as a collection of air as the collapsed lung is portrayed by a thin line demarcating the pleural edge. Specifically, the upright posteroanterior angle can confirm and accurately determine the size of the pneumothorax [12].

A computed tomography (CT) scan is obtained if the diagnosis is inconclusive. This modality can detect a small pneumothorax and differentiate this from other lung pathologies. CT studies can also be used to monitor the management and progress of these patients.

• Right Axis Deviation

  These findings include axis deviation, T-wave inversion, and right bundle branch block. When an ECG has the arm leads incorrectly placed, the ECG will display right axis deviation and inversion of the P waves in lead I. [ncbi.nlm.nih.gov]

• Inverted P Wave

  An ECG was administered; findings indicated reversal of the arm leads (right axis deviation and inverted P waves in lead I), but there was no actual limb lead reversal present. ECG findings resolved upon resolution of the pneumothorax. [ncbi.nlm.nih.gov]

• Pleural Effusion

  Re-expansion pulmonary edema (RPE) is a rare but potentially fatal complication that can occur following rapid lung expansion while managing patients with pleural effusion or pneumothorax. [ncbi.nlm.nih.gov]

  effusion, not elsewhere classified J91 Pleural effusion in conditions classified elsewhere J91.0 Malignant pleural effusion J91.8 Pleural effusion in other conditions classified elsewhere J92 Pleural plaque J92.0 Pleural plaque with presence of asbestos [icd10data.com]

  […] adhesions pleural effusion pleural space pneumothorax in tuberculous pneumothorax occurring pneumothorax space previously healthy person pulmonary tuberculosis reach the pleural recovery recurrent pneumothorax ribs severe simple pneumothorax sions spontaneous [books.google.com]

  effusions are commonly present If chest radiograph is taken in supine position, signs of pneumothorax include: Deep sulcus sign; lucency along the costophrenic angle is abnormally deepened Hyperlucency of the affected side CT scan is not recommended [rch.org.au]

The treatment of a pneumothorax will depend on the cardiorespiratory status, the severity of the symptoms, and the size of the defect [13] [14]. Mild cases of PSP and SSP are managed through observation while large ones require aspiration or insertion of a chest tube [15]. The latter is indicated if catheter aspiration fails to remove the air or in cases of SSP.

Some patients will warrant surgery, in which a thoracoscope is placed into the pleural space. These individuals will also need high flow oxygen.

Uncomplicated cases do not require treatment and will usually resolve in about 10 days. Recurrences occur especially in smokers and those with COPD or AIDS.

PSP is very likely caused by a ruptured subpleural bleb or bulla [1] [2] whereas SSP develops in those with underlying lung disease such as chronic obstructive pulmonary disease (COPD), cystic fibrosis (CF), infections, congenital disorders, or lung cancer [3] [4].

There may be a genetic component as well. For example, Marfan syndrome, Birt-Hogg-Dube (BHD) syndrome, and homocystinuria have been associated with PSP.

Smoking is a major risk factor as it may elevate the risk by 9 -fold [5].

The incidence of first -time spontaneous pneumothorax in men is 7.4 to 18 patients per a population of 100,000 and in women is 1.2 to 6 per 100,000 [6]. With regards to SSP, the incidence in men is 6.3 cases per 100,000 individuals and in women is 2 cases per 100,000 [7].

Normally, the pressure in the pleural space is negative due to the outward expansion of the chest wall and the intrinsic elastic recoil. Therefore, the chest has a tendency to collapse inward. Hence, when air enters this pleural space, the pressure increases while the vital capacity decreases. Additionally, there is an inverse relationship between the size of the pneumothorax and the volume of the lung. When the former expands, the latter becomes smaller.

The pathogenesis is not uniform in all individuals and has not been established with regards to how ruptured blebs or bullae could cause air to enter the pleural space [8].

Since some patients may experience recurrence. Preventive measures such as surgery may be beneficial in these patients. Surgery involves repairing the weak sites of the lung and strengthening the pleural layers by suturing them to each other.

Spontaneous pneumothorax (SP) refers to the presence of air in the pleural space. It may occur as a primary spontaneous pneumothorax (PSP) or secondary spontaneous pneumothorax (SSP) due to different etiologies. The diagnosis is made clinically with the help of imaging. Management of this condition depends on numerous factors.

What is a spontaneous pneumothorax?

This is a condition in which air enters the space between the chest wall and the lung. It may occur spontaneously, or secondary to lung diseases. Smoking increases the likelihood of developing this especially in individuals in their 20s and 30s.

What are the symptoms?

• Sharp chest pain that spreads to shoulder, neck, or abdomen
• Shortness of breath
• Dry cough

How is it diagnosed?

The clinician will ask the appropriate questions, perform a physical exam and order imaging tests such as chest x-ray and possibly a CT scan.

How is it treated?

Mild cases can be observed without any active treatment . Severe cases will require drainage of the air by either aspiration or insertion of a chest tube.

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